Archives of Sexual Behavior (letter to the editor)

NCSF was asked by thge DSM Paraphilias subworkgroup to respond to their proposed changes to the DSM's consensual paraphilias. This is our letter to the editor of the Archives of Sexual Behavior that was published on July 15, 2010.

The DSM-V Paraphilias Subworkgroup's suggested revision to differentiate between paraphilias and Paraphilic Disorders appears to be a step forward in depathologizing unusual sexual interests. Paraphilia diagnoses are regularly misused in criminal and civil proceedings as an indication that individuals cannot control their behavior; these individuals turn for assistance to the National Coalition for Sexual Freedom (NCSF), a national advocacy organization that advances the rights of, and advocates for consenting adults in the BDSM-leather-fetish, swing, and polyamory communities.

One recent child custody case referred to NCSF illustrates the common misunderstanding that legal and social service professionals have with the DSM-IV-TR, and is the first documented reaction to the proposal to differentiate between paraphilias and Paraphilic Disorders. The children were removed in July 2009 while psychological evaluations were performed on the mother and the children, which concluded there was no mental illness.[1} However the case worker with the Department of Social Services Children's Division in the Midwestern state where this case occurred sent the following January 21, 2010 letter to the mother’s court appointed psychologist: (DSS, 2010):

"With regards to [mother's] alternative lifestyle; can she separate this from her parenting? There has been some questions arise from other team members regarding her sexual sadism. These are as follows:

"We were made aware at the last FST meeting that while all parties involved have seen the information provided regarding [mother's] blog and website, no action has been taken to determine how it affects the children or is factored into the stated case goal of reunification with [mother]. The following information is relevant:

A. Sexual Sadism is considered a form of paraphilia in accordance with the DSM-IV-TR.

B. [Mother] admitted in court on March 9, 2009 that she was a "domme" – slang for a female sexual sadist.

C. Sexual Sadism involves inflicting pain and suffering on another individual in order to achieve sexual arousal." …

"Sexual sadism on the web has the following information: 'The essential feature of sexual sadism is a feeling of sexual excitement resulting from administering pain, suffering or humiliation on another person. In extreme cases, sexual sadism can lead to serious injury or death for the other person. According to the DSM these catastrophic results are more likely when the paraphilia is diagnosed as severe, and when it is associated with antisocial personality disorder.[2] They may experience distressed or impaired functioning because of the sadistic behaviors or fantasies. This distress and impairment may be due to the fact that the partner is not consenting. The diagnosis of sexual sadism is complicated by several factors, beginning with the fact that most persons with the disorder do not voluntarily enter therapy.'"

"[Mother] indicated she gave up this lifestyle in March. However the blog and stories that were found were posted to her website in May. There are concerns that she is still a moderator of the [BDSM] yahoo group. I have attached pages from her website in hopes that you can explore with [mother] her current involvement with this alternative lifestyle."

The CPS letter concludes with the recommendation that: "Even though [mother] is complying with attendance in therapy, we feel the above issues need to be explored and addressed."

At the final permanency hearing in February, 2010 the mother's lawyer submitted to the judge the proposed revisions for the DSM-V to separate the paraphilias from Paraphilic Disorders, resulting in a court determination to re-evaluate her entire case. The judge specifically chastised the Department of Social Services for not being aware of the proposed changes for the DSM-V. Based on the proposed revisions, in March the mother was awarded custody of three of the children, with the father retaining custody of one child in order to take advantage of his health care coverage.

As this example shows, when individuals who practice BDSM are brought to the attention of authorities, they are regularly misdiagnosed with a mental disorder. In 2009, NCSF was asked for help by 132 people regarding child custody/divorce issues directly involving their alternative sexual practices (NCSF, 2009). The year before, a total of 157 individuals contacted NCSF for help with child custody/divorce issues (NCSF, 2008). In total, almost 500 people each year request help from NCSF because of discrimination or persecution due to their alternative sexual practices.

Therefore the implications of "ascertaining a paraphilia" and "diagnosing a paraphilic disorder" are critical to depathologizing consensual paraphilias. I am concerned that if sexual sadism receives its own diagnosis code separate from Sexual Sadism Disorder, social services and legal professions will continue to think that anyone who practices consensual sexual sadism (or sexual masochism, fetishism and transvestic fetishism) therefore has a mental disorder.

The consensual paraphilias should be mentioned as the healthy comparison to a Paraphilic Disorder, much like various sexual behaviors are referred to in the proposed Hypersexual Disorder. Cybersex and masturbation don't have separate diagnosis codes in the DSM, and it is equally erroneous to assign separate codes for the paraphilias when they are not mental disorders or of clinical concern. For the same reason, the consensual paraphilias shouldn't be listed among the V-Codes.

Separating sexual behaviors (paraphilias) from the mental disorders (Paraphilic Disorders) is the first step in depathologizing consensual alternative sex. The second step is defining what exactly constitutes clinically significant distress. NCSF often consults with individuals who suffer distress and impairment in their social and occupational lives (ie. interpersonal difficulties) because their desires conflict with current societal standards. These standards stem in a large part from the DSM itself: pathologizing unusual sexual interests has led to increased discrimination and discouraged individuals from seeking treatment for physical and mental health problems (Wright, 2008).

A distinction must be made in the DSM-V between distress imposed by societal stigma, and distress that is generated internally. As seen in the above referenced child custody case, mental health professionals are not the only ones who consult the DSM. When attorneys, judges, and social workers read the diagnoses in the DSM, they see "distressed or impaired" as the determiner of mental illness. Without a comprehensible definition, they look at the individual who is on trial or in a child custody battle, and that individual certainly appears distressed. They even speculate that if the individual gave up their BDSM practices, then their life wouldn't be in disarray, so clearly they must be suffering a mental disorder because their sexual behaviors are obligatory or "obsessive" (DSS, 2010).

Therefore the current list by which distress and impairment are diagnosed must be rejected: 1) are obligatory, 2) result in sexual dysfunction, 3) require participation of nonconsenting individuals, 4) lead to legal complications, or 5) interfere in social relationships. Legal complications and interpersonal difficulties are common consequences of the stigma and discrimination against BDSM practices. In the Second National Survey of Violence & Discrimination Against Sexual Minorities, a total of 1,146 (37.5%) of the respondents indicated that they had either been discriminated against or had experienced some form of harassment or violence (Wright, 2008). As a result, 60% of the 3,000 respondents are not "out" about their BDSM interests; the stress of being closeted and/or coming out promotes distress and impairment in these individuals, similar to that experienced by homosexuals.

In addition, once a Paraphilic Disorder is diagnosed, can it ever be in remission? If so, what are the mechanisms for determining that? If the distress and impairment are resolved, does the individual go back to the ascertainment category? As of now, once a mental disorder is diagnosed, it appears to apply for the lifetime of the individual.

Finally, it must be made clear that Paraphilic Disorders are extremely rare. In particular, the descriptive text for Sexual Sadism Disorder needs to clearly state that it is limited to forensic populations, and, as Krueger (2009) states, "virtually all of the published papers using DSM criteria for Sexual Sadism have been done on studies of forensic populations." This will help prevent the conflation of those who practice consensual paraphilias with those who have a Paraphilic Disorder.

[1] All names and locations have been removed to protect the identity of those involved.

[2] Bolded in original letter despite there being no evidence the mother has antisocial personality disorder.